Nursing Investigation Results -

Pennsylvania Department of Health
WESLEY ENHANCED LIVING AT STAPELEY
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WESLEY ENHANCED LIVING AT STAPELEY
Inspection Results For:

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WESLEY ENHANCED LIVING AT STAPELEY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated Survey in response to a complaint completed on September 12, 2019, at Wesley Enhanced Living at Stapeley, it was determined that Wesley Enhanced Living at Stapeley, was not in compliance with the following Requirements of 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observation, review of clinical record, facility documentation and interviews with facility staff, it was determined the facility failed to ensure a safe environment was maintained during a resident transfer from bed to wheelchair, and from wheelchair to toilet for one of three clinical records reviewed (Resident R1).

Findings include:

Clinical record review for Resident R1, revealed a physician's order dated, September 1, 2019, which indicated a diagnosis of; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left side of body, (a mini stroke affecting left side of body), pain in left hip and anxiety disorder.

Review of Physical Therapy documentation dated, March 4, 2019, indicated, Resident R1, was to be transferred at all times, by using the sit-to-stand.

Continued review of Resident R1's clinical record revealed a fall risk assessment dated, August 6, 2019, which indicated Resident R1, was a high risk for falls and unable to stand and/or bear weight with assistance.

Further review of Resident R1's clinical record revealed a quarterly, MDS, (Minimum Data Set - periodic assessment of needs), dated August 7, 2019, which indicated, Resident R1, required extensive assistance, (resident involved in activity, staff provide weight-bearing activity), and two plus person physical assist. Care plan dated, March 8, 2019, related to impaired physical mobility, indicated, "Resident R1, will be transferred with sit-to-stand lift, (are specifically designed to secure patients during transfers from a seated position to a standing position, enabling quicker, easier, and safer patient lifting and transfer)."

Review of facility documentation, titled, "24 hour Summary", revealed an indication dated, August 19, 2019, at 10:30 p.m. "Resident R1, not to stand on feet any more and to use sit-to-stand, for all transfers". An interview with Employee E8, Social Worker, on September 12, 2019, at 12:45 p.m. confirmed this information about Resident R1, was shared during the morning staff meeting on August 20, 2019.

Observations conducted of Resident R1, on September 12, 2019, from 11:25 a.m. - 11:55 a.m. revealed Resident R1, was transferred from sitting on the side of her bed into her wheelchair, by two nurse aides, Employee's E3 and E4. Both Employees E3 and E4 were observed standing on each side of Resident R1, lifting her together, by placing their arms under the resident and sitting Resident R1 into her wheelchair.

A second observation, was conducted of Employee's E3 and E4, which revealed that again nursing assistant, Employee E3 and Employee E4 placed there arms under Resident R1, while she was sitting in her wheelchair, standing her up on her toes, both Employee E3 and E4, than used on of there hands to pull down Resident R1's pants, remove brief, while keeping one hand under her under-arm, all while Resident R1, was standing on her toes, than sitting her on the toilet.

A third and final observation was made of Employee's E3 and E4, placing there arms under Resident R1, lifting her off the toilet, standing her on her toes, each employee than keep one hand under her under-arms, use one hand to put on a brief and than pulling up her pants with the same hand while still keeping one hand under her under-arm, all while she was standing on her toes. Employee's E3 and E4, than sat Resident R1 in her wheelchair.

At the end of the observation an interview with Employee's E3 and E4, Certified Nurse Aides, Employee E5, Licensed Nurse and Nursing Home Adminsitrator, indicated and confirmed that Resident R1, should have been transferred during the three observations by using a sit-to-stand lift, as was indicated in the Care tracker, (CNA - documentation and communication system, that indicates how care and services are to be completed for an individual resident).

An interview with the Nursing Home Adminstrator and Director of Nursing on September 12, 2019, at 2:15 p.m. confirmed the two nurse aides did not adequately transfer Resident R1, during three transfer observations, by using the sit- to-stand lift.

The facility staff did not adequately transfer Resident R1 putting the resident at risk of accidents.


42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 11/27/18

28 Pa Code 201.14(a) responsibility of licensee
Previously cited 11/27/18

28 Pa Code 201.18(b)(1) Management
Previously cited 11/27/18

28 Pa Code 211.10(c) Resident care policies
Previously cited 11/27/18

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 11/27/18

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 11/27/18


 Plan of Correction - To be completed: 10/19/2019

A. The care plan for affected Resident regarding transfer method was reviewed and updated.
B. All Residents with transferring care plans had their care plans reviewed / kardexes and updated if necessary as it pertains to their transfer techniques.
C. Community DON and or designee will re-educate all Nursing personnel on writing and implementing transfer care plans. All Resident care plans will be reviewed and updated at care conferences at least quarterly.
D. DON or designee will audit transfer care plans of five Residents weekly for four weeks and then five residents monthly x three months with results reported the community CQI committee meetings.


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